Though a spike in heroin deaths has raised concerns in many Wisconsin communities, prescription opioids still claim more lives in the state — killing about 300 people each year, according to recently released state data.
"Sometimes I worry we're addressing heroin to the detriment of continuing our work on the prescription drug issue, and we won't get anywhere unless we address both," said Dorothy Chaney, president of the Wisconsin Community Health Alliance.
Prescription opioids are the primary gateway to heroin use, but they have remained persistently deadly even as heroin use and deaths have soared. Between 297 and 329 people died from prescription opioids each year from 2006 to 2012, as heroin deaths rose five-fold, according to the state Department of Health Services. Statistics from 2013 are not yet available.
Opioids — such as OxyContin, Percocet and Vicodin — are narcotic drugs typically used for pain relief that contain a synthetic form of opium, the core ingredient in heroin. Abusers can be curious teens, drug addicts looking for a different high or older adults suffering from pain who start with a legitimate need but slide into addiction.
For 20-year-old Appleton resident Nadine Machkovech (RT Youth Outreach Director), the pills provided relief from a difficult reality starting about three years ago.
"I was going through a hard time, I got into some trouble, and I had a family member actually give me a Percocet one morning to help me go to school, because I didn't want to go to school anymore," said Machkovech, who grew up in Beaver Dam. "After that it just kind of became my best friend. … I just kept using more and more."
At her worst Machkovech was snorting or injecting pills four to eight times a day, as much as she could afford. She recalled several near-overdoses — her lips would turn purple and her eyes roll upward.
"Four or five minutes later I would wake up or snap out of it, and I would just want to do some more right away," said Machkovech, who got clean in December after a friend died of a drug overdose. "I was so close to dying so many times."
Wisconsin's prescription drug death toll was 324 in 2012. Louis Oppor, a section chief specializing in substance abuse with the state health department, said it isn't clear how many of the deaths were related to non-medical drug abuse and how many to accidental overdoses of legitimate prescriptions. The tally includes 32 suicides.
(Story continues below photo: Read how easy it is to obtain pills.)
Misused pills have left their mark throughout the state, with all but six counties reporting at least one opioid death from 2006 to 2012.
The highest deaths per capita — about seven per 10,000 residents — came in Kenosha and Milwaukee counties in southeastern Wisconsin, and Langlade and Vilas counties in the northern reaches. Other counties with concentrations among the 20 highest include Adams, Dodge, Manitowoc and Winnebago.
In 2012, 1.9 million Americans abused a prescription painkiller — a category comprised largely of opioids — for the first time, according to the National Survey on Drug Use and Health. Nearly 70 percent of those abusing prescription drugs obtain them from friends or relatives, the survey found.
Chaney said users often perceive prescriptions as safer than heroin or other street drugs since they have a legitimate medical use. But consequences can be fatal when users exceed prescribed dosages, mix medications or take drugs in ways not intended by doctors.
She said the prescription opioid abuse has grown due to easy availability and a culture of pill popping.
"The reality is many households, if not most, have narcotics in them at some point, and in many cases that's where the addiction begins," Chaney said. "In many cases, patients aren't happy when they leave the doctor's office unless they've got a prescription in their hand."
The state's Prescription Drug Monitoring Program, which was launched in July 2013 but includes prescriptions for the full year, recorded 10.3 million prescriptions last year. That's enough to medicate the state's entire population for almost 40 days.
Opioids were the most commonly dispensed drug, with Vicodin and its generics accounting for 20 percent of all prescriptions dispensed in the first quarter of 2014 — nearly three times more than any other drug. OxyContin and Percocet also ranked near the top at about 6 percent each.
(Story continues below graphic: Read how cops struggle to stop criminal abuse of pills.)
Jim Bohn, special agent in charge of the Drug Enforcement Administration's Milwaukee office, said prescription drug abuse is more difficult to investigate and prosecute than street drug use since medications also have a legitimate purpose.
"If you have a doctor who may be prescribing outside his medical practice, those are tough cases to make," Bohn said.
Prescription drugs can make it to the street through employee theft at health care facilities or users who are "doctor shopping" — using multiple doctors and pharmacies to get more prescription drugs than allowed, said Brad Dunlap, who heads a drug enforcement unit in east-central Wisconsin. Few abusers doctor shop, but those who do can supply a large circle of users, he said.
"It's important to understand that the majority of prescribers and (prescription holders) are using this stuff appropriately and that it serves a very important function," Dunlap said. "It's just a very, very volatile category of drug."
The State Crime Lab has seen a steady increase in opioid cases in the past decade, rising from 170 in 2004 to 640 in 2013, according to the state Department of Justice. Nationwide, 28 percent of police agencies reported controlled prescription drugs as the greatest drug threat last year, compared to less than 10 percent in 2009, according to the 2013 National Drug Threat Survey.
Robert DesJarlais, director of security operations for Aurora Health Care, said the system's 200-plus facilities combat internal theft by requiring employees to scan ID cards to access narcotics and by regularly auditing inventories. And checks are in place to identify doctor shopping within the Aurora network, allowing providers to limit access to drugs if the person is willing to seek help, or referring them to police if they're not. But that becomes much more challenging when users go outside the network.
"It's one of those things — just like any criminal activity — when you think you have your controls in place, they find different ways to beat it," DesJarlais said.
Some solutions already implemented
Officials hope the tide is turning after implementingsome of the 32 recommendations identified in a 2012 prescription drug abuse report by the State Council on Alcohol and Other Drug Abuse.
The state has established a program to monitor all dispensed prescriptions, expanded drug take-back programs and launched a federally funded pilot program based on the report.
The pilot program, which began in January 2013, involves the Menominee Indian Tribe and nine counties chosen based on prescription drug abuse rates, including Milwaukee and nearby counties, as well as central and northern areas such as Adams and Lincoln counties. Initiatives include community education, training police to better recognize prescription drug use, and training for health professionals, such as updated prescribing practices for emergency rooms.
Oppor, of the state health department, said doctors need a better understanding of the risks of narcotic drugs and how to treat addictions. He is not a doctor but based his opinion on conversations with doctors around the state.
"It's really trying to intervene at the point where individuals who no longer have a need for the pain medication receive the proper treatment to taper off," he said. "I'm sure most of this is not done intentionally, I think there's just a lack of understanding and a lack of training as they're going through medical school."
Dr. Michael Miller, medical director of the Herrington Recovery Center in Oconomowoc and a past president of the American Society of Addiction Medicine, agreed more training is needed. He said doctors can take extreme approaches in light of opioid abuse, with some refusing to prescribe opioids at all and others signing off on strong, long-term prescriptions that are especially susceptible to abuse.
"There is a need for a better-educated workforce, because some of the questions are pretty nuanced, and there are interfaces between medicine and law and education that are complicated and can make practicing physicians anxious," Miller said.
Others steps Miller suggested to curb abuse include limiting the dosage of initial pain-relief prescriptions to three to five days and training doctors to better educate patients on the risks of addiction and the need to properly secure and dispose of medication.
Chaney, the health alliance president, said drug take-back programs are critical because many people still don't realize the danger their medicine cabinets pose to children or other drug-seekers. The initiatives allow residents to drop off expired and unused prescriptions for disposal at various community locations.
The latest such effort showed major progress in Wisconsin, as 50,000 pounds of prescription drugs were collected in a statewide drug take-back in April, according to the DEA. That was the third-largest total in the nation, behind only California and Texas.
But the long-term solution requires a cultural shift, Chaney said. She said drug abuse needs to be seen as a symptom rather than a problem.
"The reality is that unless we work on primary prevention — on preventing kids from wanting to change their reality — we're going to be chasing one epidemic after another after another," she said. "That's the Holy Grail for us in prevention is doing environmental strategy so that we reduce access to drugs, create more resilient children and create stronger family units so kids are supported in making healthier choices."
Eric Litke: 920-453-5119, or firstname.lastname@example.org; on Twitter @ericlitke.
Does drug monitoring program go far enough?
The July 2013 launch of the Prescription Drug Monitoring Program in Wisconsin is among the most noteworthy steps taken to limit medication abuse, but some say its effectiveness is limited because a key element is optional.
The database requires prescription dispensers to record every drug given out, allowing doctors to see what medication a patient has received and limit "doctor shopping" — the practice of visiting multiple doctors or pharmacies to get more drugs than should be allowed.
But doctors are not required to check that database, and as of late June less than 8 percent of authorized prescribers in the state had registered to access it, according to the state Department of Safety and Professional Services, which administers the database.
"I think mandatory reporting … is necessary for the thing to have any teeth," said Brad Dunlap, who heads a police drug enforcement unit in east-central Wisconsin. "The abusers will quickly find out who's reporting and who's not and then they'll start frequenting the places that they either know or believe are not (using the database) which of course will defeat the purpose of having it in the first place."
The state is expanding the program's reach by integrating the drug data with electronic health records for the Marshfield Clinic system and health care providers that use the Wisconsin Statewide Health Information Network, using money from a $388,000 federal grant, said Hannah Zillmer, spokeswoman for the state health department's Department of Safety and Professional Services. That could allow prescription information from the database to pop up automatically for prescribers, eliminating the need to run a separate database check.
The database identifies the most common drugs prescribed in the state and the volume of prescriptions. In the first quarter of 2014, the program recorded 2.6 million prescriptions, of which 20 percent were Vicodin and its generic equivalents.
Police can access the database with a court order, and did so an average of 28 times per month last year.
— Eric Litke, Gannett Wisconsin Media Investigative Team
A database of local drug addiction resources is available atwww.findtreatment.samhsa.gov, a website maintained by the U.S. Substance Abuse and Mental Health Services Administration.